[Authored by Olivia Johnson, Alice Dunning and Judith Johnson]

Healthcare research can feel out of touch and out of step with clinical demands and priorities. It’s usually a slow process, often riddled with delays, and it may not address the immediate questions healthcare staff are asking.

As healthcare researchers, we have been challenged about the point and purpose of our work. After all, we’ve been asked, doesn’t research usually just confirm what we know by common sense, anyway? Aren’t the true advances in healthcare made through common sense clinical observations and logical assumption? Here, we present four reasons why healthcare research is needed (or, four ways that common sense has not been enough).

1. Widely practised treatments based on common sense clinical knowledge have been found to be ineffective (or harmful) when tested by research.

One clear example of this is the use of oxygen therapy as emergency treatment following a heart attack. For over 100 years this was considered common sense and routine, based on knowledge that the blocked artery would prevent oxygen from reaching the heart. However, in 2009 a review of research studies testing this intervention reported counterintuitive results [1]. Rather than compensating for the lack of oxygen to the heart, the review found that oxygen treatment increased, rather than decreased, the size of the area affected by lack of oxygen. These studies have started to raise debate about the guidelines for emergency oxygen treatment, challenging standard healthcare practices and moving this field forwards [2].

Reaching back further in time, in the middle of the 20th Century, we can find a similar example of counterintuitive research results in the work of Ignacio Ponseti. Ponseti was an Orthopaedic Surgeon who began researching Club Foot, a condition where one or both of a child’s feet are turned inwards and downwards. At the time, based on clinical knowledge and common sense, it was widely assumed that Club Foot should be treated surgically [3]. Ponseti, however, began to recall individuals who had had this surgical treatment twenty years later. Contrary to expectation, his research found that many of these patients were suffering from rigid, weak feet [3]. Ponseti delved into the research literature for answers, drawing on papers published as far back as 1872 [4] to develop a treatment based primarily on plaster casts [5]. His results were impressive, suggesting that 71% of feet treated with his method showed a good outcome 5-12 years later [3]. The downside was that his procedure was slow, involving phased treatment that lasted months. It felt counter-intuitive and undesirable compared to a surgical intervention which had much quicker results. Because of this, Ponseti’s approach was regarded as outlandish, and for years many people viewed him as crazy [6].  It wasn’t until the 1990s, when he had produced further promising research results and word began to spread, that his evidence-based approach became the ‘norm’.

A more current example like this comes from the field of miscarriage research [7]. Based on knowledge that the hormone progesterone is key to maintaining a healthy pregnancy, a common sense treatment for women at risk of miscarriage has been to prescribe progesterone supplements after a positive pregnancy test result. However, when it was put to the test in a large-scale study last year, this treatment was not found to be effective. Contrary to expectations, women prescribed progesterone supplements had almost exactly the same risk of miscarriage as women prescribed a placebo version of the hormone [7]. In the absence of promising new interventions for miscarriage, this result was disappointing to the many couples affected by this problem. On the other hand, it could be the evidence that researchers need to spur them on to find new answers. Let’s watch this space!

2. Healthcare research has proved that interventions that are intuitively bizarre can in fact be helpful.

Sometimes the strangest things can help, and without research, it’s hard to see how these kind of treatments would have come to light. One example comes from research into IVF (in-vitro fertilisation), where success rates continue to be disappointingly low. However, recent hope has come from a treatment known as the “endometrial scratch”. As it sounds, this is literally where the inside of a woman’s uterus is scratched prior to undergoing IVF. Although strange sounding, evidence that this may be beneficial first came from research in guinea pigs in 1907 [8]. In the past decade studies have begun to explore this treatment for boosting IVF success rates in humans. When reviewing these studies together, a recently published paper concluded that the endometrial scratch improves IVF success rates in women who have undergone previously failed attempts, who might otherwise have low chances of success [8].

Other counterintuitive treatments have come from research into physical health symptoms which cannot be explained medically. You may initially think that these problems must be rare, and that physical health problems on the whole require a medical intervention targeting the body. However, research has told us that around half of patients seen by hospital doctors may be affected by medically unexplained symptoms [9]. Armed with this knowledge, psychologists theorised that these symptoms may be psychologically influenced, and developed psychotherapeutic treatments to address them. Research testing these treatments has been promising, and a recent review of these studies found that in all cases, psychological therapy reduced the severity of medically unexplained symptoms [10].

3. What common sense would suggest is a problem, isn’t always a problem

In healthcare, it can sometimes seem that there are a lot of things that need improving. Research can just be an added burden to this, an extra job on top of the normal clinical caseload. However, sometimes research can help reduce that to-do list, showing us that some things may be fine left unchanged.

A great example of this is research into interruptions on wards. The conventional view has long held that distractions and interruptions are a threat to patient safety. They take attention away from the task in hand and break clinicians’ concentration. However, research suggests that the real picture isn’t nearly so clear. Whilst interruptions in surgical settings have been linked with deteriorations in patient safety [11], research in ward settings has highlighted the benefits of being interrupted. For example, one study found that interruptions provided important information for staff, with 11% of them communicating knowledge that improved patient safety [12]. Other research has found that interruptions may help staff to stay alert by keeping them in a heightened state of arousal and eliminating boredom [12].

Taken together, these studies oppose the common-sense view that interruptions should be eliminated in ward settings and suggest that distractions are not always dangerous. Indeed, interruptions can keep clinicians alert and informed in some settings, and efforts to remove and reduce them could have unexpected consequences. Good news for clinicians – this is one thing that can be left unchanged!

4. What is common sense to clinicians isn’t always common sense to other people, and research evidence can lead to shared knowledge.

Part of our own research focuses on healthcare staff burnout, and we have found evidence suggesting that when staff are burnt out, safety and quality of patient care suffers [13]. In our discussions with healthcare staff we have been told that our research is obvious, common sense, and common knowledge. After all, anyone working on a ward can see that this is the case. However, gathering data demonstrating this link can help to explain and describe it to the public and policy makers, who may not fully understand the daily challenges of healthcare work. Conducting this kind of research can begin to quantify this association. For example, if a nurse is suffering from moderate burnout due to difficult working conditions, just how much is the quality of the care they can provide likely to suffer? We don’t have the answer to that one yet, but it’s these kind of questions we are keen to answer. We may be stating the obvious, but what seems obvious to you or me may not be so clear to everyone else.

So where now?

It seems pretty clear to us that research is necessary. It overturns false assumptions, finds strange new answers to problems, can help clinicians focus on the most pressing problems, and can justify the resources that clinicians need.

On the other hand, we are under no false illusions that the research process is perfect as it is. It can take years to secure funding for a project that is clearly needed, years more to undertake that project, and months more again until that research may be published and publicised. In the worst cases, by the time funding has been secured for a project, the landscape of the NHS has changed to such an extent that the project needs to be overturned entirely.

A need to improve the peer-review process

It seems to us that there is one clear place these time lines could be sped up: the peer-review process. Peer review is where grants and papers are critiqued by other researchers, and it can often take several months. The reason for this? Generally speaking, reviewers are not paid, and they provide these reviews anonymously. So highly qualified, busy professionals are expected to do this in their spare time, for virtually no personal gain whatsoever. In a pressurised work environment, this crucial work falls to the bottom of a long to-do list. To us, one obvious improvement could be to start incentivising reviewers. We’re seeing steps towards this with initiatives such as offering reviewers credits (reviewercredits.com; @reviewercredits), but more is needed here. There need to be tangible rewards for reviewing that will motivate reviewers to prioritise this task.

Time to build bridges

We also think there is clear potential for researchers and clinicians to work more closely together. Researchers may have research expertise, but they need the hands-on knowledge of clinicians to know where to apply this. On the other hand, clinicians may have the best ideas, but they need to reach out to researchers to help develop that all-importance evidence base.

References

  1. Wijesinghe, M., Perrin, K., Ranchord, A., Simmonds, M., Weatherall, M., & Beasley, R. (2009). Routine use of oxygen in the treatment of myocardial infarction: systematic review. Heart, 95(3), 198-202.
  2. http://www.clinmed.rcpjournal.org/content/11/6/628.2.full
  3. Brand, R. A. (2009). Clubfoot: Etiology and Treatment Ignacio V. Ponseti, MD, 1914–. Clinical orthopaedics and related research, 467(5), 1121-1123.
  4. Dobbs, M. B., Morcuende, J. A., Gurnett, C. A., & Ponseti, I. V. (2000). Treatment of idiopathic clubfoot: an historical review. Iowa orthopaedic journal, 20, 59-64.
  5. Ponseti, I. V., & Smoley, E. N. (1963). Congenital club foot: the results of treatment. J Bone Joint Surg Am, 45(2), 261-344.
  6. http://www.bbc.co.uk/programmes/b06zs22x
  7. Coomarasamy, A., Williams, H., Truchanowicz, E., Seed, P. T., Small, R., Quenby, S., … & Bloemenkamp, K. W. (2015). A randomized trial of progesterone in women with recurrent miscarriages. New England Journal of Medicine, 373(22), 2141-2148.
  8. Ko, J. K. Y., & Ng, E. H. Y. (2016). Scratching and IVF: any role?. Current Opinion in Obstetrics and Gynecology, 28(3), 178-183.
  9. Nimnuan, C., Hotopf, M., & Wessely, S. (2001). Medically unexplained symptoms: an epidemiological study in seven specialities. Journal of psychosomatic research, 51(1), 361-367.
  10. van Dessel, N., Den Boeft, M., van der Wouden, J. C., Kleinstäuber, M., Leone, S. S., Terluin, B., … & van Marwijk, H. W. (2015). Non-pharmacological interventions for somatoform disorders and medically unexplained physical symptoms (MUPS) in adults, a Cochrane systematic review. J. Psychosom. Res, 78(628), 10-1016.
  11. Sevdalis, N., Undre, S., McDermott, J., Giddie, J., Diner, L., & Smith, G. (2014). Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments. World journal of surgery, 38(4), 751-758.
  12. Sasangohar, F., Donmez, B., Trbovich, P., & Easty, A. C. (2012, September). Not all interruptions are created equal: positive interruptions in healthcare. In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (Vol. 56, No. 1, pp. 824-828). SAGE Publications.
  13. Hall, L. H., Johnson, J., Watt, I., Tsipa, A., & O’Connor, D. B. (2016). Healthcare Staff Wellbeing, Burnout, and Patient Safety: A Systematic Review. PloS One, 11(7), e0159015.

This article was originally published on 31st August 2016 on healthprofessionalofinfluence.com (a now inactive website). 

[Authored by Louise Hall & Judith Johnson]

The NHS is rarely out of the headlines. Stories of growing waiting lists, breached targets and funding concerns abound. Some coverage has also considered the impact of these problems on NHS staff. Doctors have come forward to speak of the pressures of working long, antisocial hours in under-staffed, unsupportive environments. These articles have been met with scepticism by some – after all, aren’t doctors well-respected professionals working in modern healthcare facilities? And if things are tough for them, what has that got to do with us, their patients?

The real story

Truck drivers are forced to break every 4.5 hours for at least 45 minutes to prevent fatigue3, but doctors aren’t. In fact, doctors aren’t entitled to any break at all until they’ve worked for 6 hours, and then this break is only 20 minutes long. Despite the European Working Time Directive1 stating that the average number of hours a week must not exceed 48, this is actually spread across a 26 week time period, often resulting in doctors working in excess of 90 hours some weeks.

Although GPs hours may not be as long as those based in hospitals, their timetable is no less demanding. In addition to seeing as many as 40 patients a day, they make patient calls, house visits, and deal with all the paper work required to run a successful practice4. The average GP practice doesn’t have scheduled breaks, so staff are lucky if they have time for a proper lunch break or a rest from the intensity of continuously problem-solving patient cases.

The upshot

Research suggests that working such long hours, with such high levels of responsibility, takes its toll. A whopping 46% of GPs are classed as high risk for burnout5, and 30% of all healthcare staff have a minor psychiatric disorder, such as depression6-8. This is 11% higher than amongst the general population9.

So now let’s return to our second question: What has this got to do with us, their patients?

How doctor wellbeing affects patient care

  1. If your GP is unwell, you’re more likely to be referred, and your diagnosis delayed

Doctors that are suffering from burnout are more likely to refer you for additional tests. They realize they don’t necessarily have the mental resources to make a correct diagnosis, and may go overboard ensuring you’re checked for everything. Whilst this could be a sign of thoroughness, a doctor’s job is essentially weighing up risk and decision-making, and when they are functioning well they are able to make decisions on exactly which tests are essential. When these thought processes are impaired through poor wellbeing however, the additional tests you’re sent for will cost you time, requiring multiple visits back to the hospital/doctors surgery. These tests also inflict unnecessary costs on the health service, requiring resources that could be better used elsewhere10.

  1. Your experience of care will be poor

Burnt-out doctors are less likely to engage in patient-centered communication, which alongside making your appointments less enlightening is also associated with increased referral rates11. Additionally, a study found that patients of doctors who are burnt-out were less satisfied with their care than patients of doctors who had lower levels of burnout12.

  1. There’s more likely to be a mistake on your prescription 

The PRACtISe study in 2012 examined over 6,000 prescriptions within Primary Care and found that 1 in 20 prescriptions contained an error. That equated to 1 in 8 patients! Take a guess what one of the contributing causes to these mistakes was found to be…. Yep, you guessed it, the wellbeing of the GP. Anxiety, tiredness and physical wellbeing were all factors quoted by the GPs as causes for these mistakes. These factors are manifestations of heavy workloads, competing demands and time pressures that they are faced with daily13.

  1. If your doctor is unwell, they’re more likely to make a major medical error

“Medical errors” include things like wrong or missed diagnosis and wrong site surgery. Depressed, stressed, burnt-out, and anxious doctors are all significantly more likely to make errors than those who are psychologically healthy14-17. Which makes sense – if you’re not feeling well, it’s harder to concentrate. In fact it has been found that depression, for example, reduces cognitive functioning, which is important for our reasoning, memory, and attention systems18.

  1. Sick doctors cost you money

Doctors taking sick leave costs the NHS an average of £1.7billion each year19! But who foots this bill? We all do, in our taxes. And there’s no prize for guessing what one of the biggest contributors to sick leave in the NHS is: psychological wellbeing. Stress, depression, and anxiety account for more than a quarter of all sick leave. Worryingly, the level of stress seems to be only on the rise, with GPs reporting the highest levels of stress in Spring 2015 since the beginning of an ongoing survey that started in 199820.

So, next time that you think the welfare of our doctors isn’t your problem, think again. The healthier and happier the NHS staff are, the healthier and happier we all will be.

References

  1. http://www.bma.org.uk/support-at-work/ewtd
  2. http://www.heraldscotland.com/news/13126162.Revealed__junior_doctors_working_90_hours_a_week/
  3. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/208091/rules-on-drivers-hours-and-tachographs-goods-vehicles-in-gb-and-europe.pdf)
  4. https://www.healthcareers.nhs.uk/explore-roles/general-practice-gp/working-life
  5. Orton, P., Orton, C., & Gray, D. P. (2012). Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice. BMJ open, 2(1), e000274.
  6. Calnan, M., Wainwright, D., Forsythe, M., Wall, B., & Almond, S. (2001). Mental health and stress in the workplace: the case of general practice in the UK. Social science & medicine, 52(4), 499-507.
  7. Myers, H. L., & Myers, L. B. (2004). ‘It’s difficult being a dentist’: stress and health in the general dental practitioner. British dental journal, 197(2), 89-93.
  8. Wall, T. D., Bolden, R. I., Borrill, C. S., Carter, A. J., Golya, D. A., Hardy, G. E., … & West, M. A. (1997). Minor psychiatric disorder in NHS trust staff: occupational and gender differences. The British Journal of Psychiatry,171(6), 519-523.
  9. http://www.ons.gov.uk/ons/dcp171766_310300.pdf
  10. Kushnir, T., Greenberg, D., Madjar, N., Hadari, I., Yermiahu, Y., & Bachner, Y. G. (2014). Is burnout associated with referral rates among primary care physicians in community clinics?. Family practice, 31(1), 44-50.)
  11. Stewart M, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000; 49: 796–804
  12. Anagnostopoulos, F., Liolios, E., Persefonis, G., Slater, J., Kafetsios, K., & Niakas, D. (2012). Physician burnout and patient satisfaction with consultation in primary health care settings: evidence of relationships from a one-with-many design. Journal of clinical psychology in medical settings, 19(4), 401-410.
  13. Avery, T., Barber, N., Ghaleb, M., Franklin, B. D., Armstrong, S., Crowe, S., … & Serumaga, M. B. (2012). Investigating the prevalence and causes of prescribing errors in general practice. London: The General Medical Council: PRACtICe Study.
  14. Dyrbye LN, Satele D, Sloan J, Shanafelt TD. Utility of a brief screening tool to identify physicians in distress. Journal of general internal medicine. 2013;28(3):421-7.
  15. de Oliveira Jr GS, Chang R, Fitzgerald PC, Almeida MD, Castro-Alves LS, Ahmad S, et al. The prevalence of burnout and depression and their association with adherence to safety and practice standards: a survey of United States anesthesiology trainees. Anesthesia & Analgesia. 2013;117(1):182-93.
  16. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. Jama. 2009;302(12):1294-300.
  17. Niven K, Ciborowska N. The hidden dangers of attending work while unwell: A survey study of presenteeism among pharmacists. International Journal of Stress Management. 2015;22(2):207.
  18. Linden DVD, Keijsers GP, Eling P, Schaijk RV. Work stress and attentional difficulties: An initial study on burnout and cognitive failures. Work & Stress. 2005;19(1):23-36.
  19. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108910.pdf
  20. http://www.population-health.manchester.ac.uk/healtheconomics/research/Reports/EighthNationalGPWorklifeSurveyreport/EighthNationalGPWorklifeSurveyreport.pdf

A previous version of this article was originally published on 5th February 2016 on healthprofessionalofinfluence.com (now an inactive website).